A COMEBACK SHORT OF THE

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1 September 2016 A COMEBACK SHORT OF THE TACKLING HEALTH DISPARITIES Cnsidering Health Enterprise Znes fr Nrth Carlina MARK: BY FOR Lee Dixn Albermarle State Plicy Center albemarle-statecenter.rg Think NC First Raleigh, Nrth Carlina thinkncfirst.rg

2 Table f Cntents 1. BACKGROUND Available Resurces 3 2. MARYLAND Opprtunities and Lessns Cmplementary Health Disparity Activities in Maryland 7 3. NORTH CAROLINA Nrth Carlina s Effrts t Address Health Disparities Cmplementary Health Disparity Activities in Nrth Carlina NORTH CAROLINA SHOULD CONSIDER HEALTH ENTERPRISE ZONES Ge-Mapping Cnduct Cmmunity Listening Sessins Identify and Catalg Resurces Cnvene a Statewide Cnference Cmplementary Multi-Year Effrt CONCLUSION 14 Abut the Authr Lee Dixn is an experienced health plicy manager wh has wrked at the lcal, federal, academic, and state levels in analyzing and affecting health care plicy. In 2007, Dixn established the Albemarle State Plicy Center, a nn-partisan resurce dedicated t identifying, researching, and analyzing State and Federal prgrams, plicies, and legislatin that affect the scpe, quality, delivery, and financing f healthcare in the public and private sectrs. In late 2006, Lee came t Nrth Carlina t wrk fr the General Assembly as fiscal and health plicy analyst with versight respnsibility fr the Department f Health and Human Services Divisin f Public Health, Divisin f Medical Assistance, and Health Chice Prgrams. In 2011, he left the General Assembly t becme the Directr f Plicy Research and Develpment at the Nrth Carlina Cmmunity Care Netwrks. Frm , Lee facilitated and directed NC Get Cvered, a nnpartisan initiative cmmitted t imprving health utcmes in Nrth Carlina thrugh utreach, educatin and enrllment in the health insurance marketplace. Lee hned his analytical and plicy skills during a career f researching legislatin and plicies acrss the 50 states. He directed the Health Plicy Tracking Service (HPTS) and he has held key psitins at the Natinal Institute f Mental and the HEW Task Frce t Implement the President s Cmmissin n Mental Health and began his career as a Public Health Advisr fr the Centers fr Disease Cntrl and Preventin. 1

3 What are health disparities and why d they matter? As a cuntry, we have achieved significant health imprvements ver the past century. We have benefited frm prgress in autmbile safety, better wrkplace standards, gd schls and medical clinics, and reductins in smking. But when we lk clser, within each state acrss the cuntry including Nrth Carlina there are significant differences in health utcmes accrding t where peple live, learn, wrk, and play. It is clear that nt all Americans have the means nr the pprtunity t be their healthiest. i This Issue Brief will Prvide a backgrund n health disparities and place the scial and medical determinants f disparities int cntext. Describe the innvative apprach Maryland is taking t address health disparities. Describe Nrth Carlina s current prgrams and activities, and Recmmend that NC plicymakers cnsider adpting health enterprise znes. 1. Backgrund In 2003, the landmark Institute f Medicine (IOM) reprt Unequal Treatment: Cnfrnting Racial and Ethnic Disparities in Health Care drew natinal attentin t disparities in the health care f racial and ethnic minrities. ii While in the decade since, sme disparities in health care have narrwed, disparities in the health f minrity and disadvantaged ppulatins have persisted. Health equity is the ppsite f health disparity and is achieved when everyne has a fair chance and pprtunity t attain his r her full health ptential. iii (See Figure 1) Figure 1 Giving everyne a fair chance t be healthy des nt necessarily mean ffering everyne the same resurces t be healthy, but rather ffering peple specific resurces necessary fr their gd health. Fr example, cnsider three children f different heights. Offering all the same size bench t stand n means that shrter children d nt have a fair chance t see ver the wall. Offering each child a bench t stand n that is the right size fr their height gives all children a fair chance t see ver the wall. Since the IOM issued its reprt, healthcare stakehlders and plicymakers have cme t realize that health begins where we live, learn, wrk and play. Therefre, understanding health disparities requires a fresh lk at the determinants f health itself, the mst bvius being intrinsic bilgical attributes such as age, sex, and genes. Hwever, there are ther risk factrs that affect health and are referred t as dwnstream determinants because they are ften shaped by upstream scietal cnditins. Dwnstream determinants include medical care; envirnmental factrs, such as air pllutin; and health behavirs, such as smking, seeking r frging medical care, and nt adhering t treatment guidelines. Expsure t these determinants is influenced by upstream scial determinants f health persnal resurces such as educatin and incme and the scial envirnments in which peple live, wrk, study, and engage in recreatinal activities. Incme is ne f the mst familiar scial determinants t have a striking assciatin with health. Adults living in pverty iv are mre than five times as likely t reprt being in fair r pr health as adults with higher incmes. v Educatin, like incme, has a large influence n health. Adults withut a high schl diplma r equivalent are three times as likely as thse with a cllege educatin t die befre age sixty-five. vi Cmmunities, Unhealthy behavir is partly a matter f persnal chice, but the envirnment in which peple live, wrk, and play influences their health behavir and status. A family may desire t eat a healthy diet but find nutritius fds t cstly, r live t far frm a supermarket that sells fresh prduce. Parents want their children t play utside and take advantage f recreatinal pprtunities. Hwever, their neighbrhds may be unsafe, lack playgrunds r recreatinal facilities. Disadvantaged cmmunities ften have a shrtage f health primary care prviders. vii Ecnmic pprtunity, the vibrancy f neighbrhds, access t educatin and sufficient incme are cnditins set by sciety, nt by physicians, hspitals, health plans, r even the public health cmmunity. The leaders wh can best address the rt 2

4 causes f disparities may be the decisin makers utside f health care wh are in a psitin t strengthen schls, reduce unemplyment, stabilize the ecnmy, and restre neighbrhd infrastructure. Furthermre, Maryland plicymakers fund unfrtunate and persistent health disparities acrss these health indicatrs by race/ethnicity and by place f residence in the state. 1.1 Available Resurces and Actin Annually, the United Health Fundatin, alng with the American Public Health Assciatin, cllects vital public health data at the state and cunty level and issues tw seminal reprts n status f state and cunty public health America s Health Rankings Annual Reprt (AHR) is all abut actins and initiatives that can be taken by state plicymakers. The reprt ges beynd where a state is in the rankings t where it culd be. AHR uses the data it cllects t investigate why the state fell r rse in the rankings, and then examines the actins that culd be taken. Cunty Health Rankings & Radmaps Building a Culture f Health Cunty by Cunty viii is used as a g-t-surce fr lcal cmmunities in raising awareness f the brad range f factrs that matter t ur health and drive change in these areas. As a result, Maryland plicymakers directed the state s Health Quality and Cst Cuncil t cnvene a Health Disparities Wrkgrup. The wrkgrup was cmpsed f public health experts, research schlars, and cmmunity health leaders and charged with identifying strategies t reduce and eliminate health disparities. The wrkgrup chse t apply principles f ecnmic develpment and revitalizatin t public health and health care delivery. The cncept included a range f incentives, including tax credits and lan repayment t attract a range f healthcare prviders, including primary care physicians, t expand current r pen new primary care practices. Other cmmunity-level initiatives f the HEZs invlved cmmunity health wrkers (CHW) and strategies t address the medical and scial determinants f health disparities. The key recmmendatin f the wrkgrup was t implement this cmprehensive strategy and its initiatives thrugh the creatin f Health Enterprise Znes. The znes were t encmpass cntiguus gegraphic areas where the ppulatin was experiencing pr health utcmes that were cntributing t racial/ethnic and gegraphic health disparities. Tgether these reprts draw plicymakers attentin t the gaps in public health, chrnic cnditins, and health status, and rank the best t wrst cunties in a state in hw lng and hw well residents live. They encmpass a fundamental cmmitment t empwering lcal cmmunities t clse health gaps and advance health equity. The rankings were used as a wake-up call fr Maryland plicymakers t take actin. The Wrkgrup s recmmendatins became the basis fr SB 234, The Maryland Health Imprvement and Disparities Reductin Act f 2012 xi, establishing Health Enterprise Znes (HEZ) and targeting resurces t: 2. Maryland In 2012, Maryland state plicymakers became cncerned where the state fell in America s Health Rankings. Despite the state s having utstanding medical schls, the highest median husehld incme, and the secnd highest number f primary care physicians per 100,000 ppulatin, it lagged behind ther states in several key health indicatrs.ix 1) Reduce health disparities; 2) Imprve health utcmes; and 3) Reduce health csts and hspital admissins and readmissins in specific area f the State. The Act authrizes cmmunity-based rganizatins (CBO) t apply fr a range f incentives and resurces fr HEZs, including: In 2012, accrding t America s Health Rankingsx, Maryland ranked: 20th in cancer deaths, 22nd in besity prevalence and 20th verall, amng the 50 states. 1) 2) 3) 4) 31st in infant mrtality, 30th in cardivascular deaths, 3 Incme tax credits; Hiring tax credits; Lan repayment assistance, and Grant funds.

5 In the fall f 2012, Maryland s Department f Health and Mental Hygiene (DHMH) slicited applicatins frm cmmunity-based rganizatins and lcal health departments acrss the state t becme an HEZ. T be eligible fr HEZ funding a cmmunity had t: Define the gegraphic area it wuld serve, i.e. identify a set f cntiguus zip cde areas, with at least 5,000 residents. Demnstrate an ecnmic need thrugh the: Percentage f residents wh were Medicaid eligible; Percentage f wmen eligible fr the Supplemental Nutritin Prgram fr Wmen, Infant, Children (WIC); High rate f Infant Mrtality; and Reduced rate f Life Expectancy N ther risk factrs, such as the rate f strke, heart disease, asthma, HIV/STDs, r cancer were required. The DHMH believed that by minimizing the requirements a cmmunity based rganizatin (CBO) had t meet, it culd encurage a greater number f applicants t apply. T further encurage and facilitate CBOs and lcal health departments t apply, DHMH created a database by gemapping the state s 240 zip cdes by ecnmic need, infant mrtality, and life expectancy. xii Maryland s decisin and investment t ge-map the state at the zip cde level has prven t be an excellent investment in resurces. The DHMH has repeatedly used the zip cde database t identify lcal cmmunities within cunties and cities where the state plicymakers can garner the best return n investment with federal, state, and/r philanthrpic funds. The Maryland General Assembly authrized and apprpriated $16 millin fr the fur-year HEZ prgram. Each HEZ wuld develp its wn implementatin plan, based n its apprved applicatin, but, in general, each HEZ was expected t fulfill the fllwing annual sequence f gals. The annual gals were established t achieve a step-bystep prcess t fulfill the verall gals f the HEZ prgram: Create ecnmic and cmmunity-driven incentives t enhance the number f healthcare prviders, at all levels, and access t services; Reduce the utilizatin f hspital emergency rm services; Reduce hspital admissins and readmissins; Imprve health utcmes in racial/ethnic minrity ppulatins, and In fulfilling the abve gals, engage the cmmunitybased rganizatins and the business, educatin, and cmmunity leaders t recgnize and address the scial and medical determinants fr HEZ residents. DHMH received 19 applicatins frm 17 cmmunities acrss the state that were cnsidered in a tw-step review prcess. The first step was t evaluate the 19 applicatins and select 10 finalists. The secnd step was fr representatives frm the 10 CBOs t make a public presentatin t the Maryland Health Cuncil xiii. Frm the 10, five HEZs were selected fr implementatin. Table 1 Prgram Year Annual Gals Year 1 Year 2 Year 3 Fcus n capacity expansin, including HEZ healthcare prviders and cmmunity health wrkers (CHW)/case managers. Pririty areas include recruitment and training. Fcus n the prductivity f the HEZ healthcare prviders, prgrams, and CHWs, t utilize new capacity with the neediest patients. Pririty areas are prgram develpment, utreach, and additinal training. Fcus n the quality care prvided by healthcare prviders and CHWs including relevant metrics fr all persnnel. Year 4 Fcus n health utcmes hspital utilizatin and cst reductins. 4

6 Table 2 Maryland s Health Enterprise Zne Prgrams xiv Entity Mrris Blum Public Husing, Anne Arundel Medical Center Drchester Cunty Health Department Prince Gerges Health Department Lexingtn Park, Medstar, St. Mary s Hspital Bn Securs Baltimre Health System Lcatin Zne s Ppulatin Annaplis 36,805 peple in 1 zip cde Suburban Cmmunity Drchester and Carline Cunties 36,123 peple in 7 zip cdes Rural Eastern Shre Capitl Heights 38,626 peple in 1 zip cde D.C. Suburb St. Mary s Cunty 34,035 peple in 3 zip cdes Rural S. Maryland West Baltimre 137,823 peple in 4 zip cdes Urban Cmmunity Activities 1) Establish a surce f primary care at a husing facility fr senirs, s as t reduce 911 calls; 2) cncurrently serving the surrunding Latin cmmunity; and 3) imprve health utcmes fr racial/ethnic minrities. 1) Imprve utcmes & reduce risk factrs related t a variety f chrnic illnesses; 2) increase primary care and CHW wrkfrce; 3) increase access t healthy fd & physical activity; 4) imprve health utcmes fr racial/ethnic minrities; and 5) reduce ED visits and unnecessary hspital csts. 1) Increase accessibility and availability f primary care services; 2) imprve health utcmes fr racial/ethnic minrities; 3) increase CHW wrkfrce; 4) increase cmmunity s health resurces; and reduce ED visits and preventable hspitalizatins. 1) Increase primary care and CHW wrkfrce; 2) Reduce unnecessary ED usage; 3) imprve health utcmes fr racial/ethnic minrities; 4) increase cmmunity resurces that facilitate access t healthcare services and imprve the physical envirnment; and 5) implement a 16-stp Mbile Medical Rute transprtatin prviders, pharmacies, fd stres, and parks. 1) Cnnect high utilizers f healthcare t CHWs and primary care prviders; 2) imprve utcmes & reduce risk factrs related t chrnic illnesses; 3) increase percentage f residents with imprved bimetric screens; 4) imprve health utcmes fr racial/ethnic minrities; and 5) reduce ED visits and preventable hspital admissins and readmissins. 5

7 2.1 Opprtunities and Lessns The five HEZs recently cmpleted their third year, f the fur-year initiative. The activities and accmplishments t date validate the gals and cmmitments first set ut by Maryland s Health and Quality Cst Cuncil and the Maryland General Assembly t address the medical and scial determinants f health disparities amngst racial/ethnic minrity cmmunities. Cmmunity invlvement A key t the success f Maryland s HEZs, r any initiative t address health disparities is invlvement at the cmmunity level. Fllwing the General Assembly s enactment f the HEZ legislatin (SB 234), DHMH staff cnducted a series f public frums t gather cmmunity insight. The invlvement, frm the start, f cmmunitylevel stakehlders representing the interests and invlvement f healthcare prviders, faith-based rganizatins, municipal gvernment, schls, businesses, and cmmunity-based rganizatins is a key t success. In preparatin t cnducting the state-wide listening sessins, state-level plicymakers need t be briefed and made aware f bth the sci-ecnmic and medical/health determinants f health disparities, e.g. incme, educatin, and a cmmunity s envirnment. xv Obtaining buy-in and cmmitment, at the start, frm the brad cmmunity invlved and the ppulatin t be served significantly increases their cmmitment t the success f the effrt. Cncurrently, the cllabrative and crdinated effrts n the part f state-level staff and cmmunity leaders and healthcare prviders frm acrss the state will result in an effective wrking relatinship. Furthermre, it allws fr DHMH staff t partner with the HEZs in implementatin, as ppsed t slely lking ver their shulder. Ge-Mapping As nted in the text and table abve, the HEZ initiatives and services are fcused n the residents living within the cntiguus zip cdes. The five HEZs encmpass up t seven zip cdes and between 34,000 and 138,000 residents. Public health experts have cmmented t this authr n the fresight f Maryland s mapping the state by zip cde in identifying areas f greatest need with regard t health resurces and the prevalence f chrnic and acute healthcare cnditins. xvi The zip cde database assisted reviewers t identify applicatins frm areas f greatest need, it als allwed fr the HEZs, nce selected, t fcus their effrts n the residents f the cntiguus zip cdes and have a significant impact n the health status f racial/ethnic persns living in thse designated areas. This, in turn, has led t a return n investment (ROI). It als underscred the business ratinale and applicatin f ecnmic principles in the develpment and revitalizatin f public health and healthcare delivery services. Cmmunity Health Wrkers The HEZs emphasis n and implementatin f CHWs cincided with natinal healthcare refrms t identify gaps in services, emphasize cmmunicatin with patients, crdinate care, ptimize utilizatin and utcmes, and minimize csts. The effectiveness f the CHW s respnsibilities was enhanced by the Maryland s utilizatin f its state health infrmatin exchange. The Chesapeake Reginal Infrmatin System fr ur Patients (CRISP) prvided the HEZs and ther healthcare prviders with daily ntificatin f services HEZ patients were accessing, e.g. emergency departments and hspital admissins and readmissins. Hspitals have their wn patient infrmatin systems, s HEZs affiliated with hspitals received hspital alerts n the similar activity f HEZ residents, including high-end utilizers. Recently and cincidentally, Kaiser Health News reprted n the rle f CHWs in Maryland. The fllwing is an excerpt frm the article: hspitals acrss the cuntry are turning t CHWs in a bid t revamp patient care. They are using these aides t strengthen their relatinships with patients and surrunding neighbrhds imprving the cmmunity s health and, alng the way, their wn finances. Part f it is spurred by the 2010 federal health refrm, which intrduced a number f changes in hw Medicare pays hspitals. Similar effrts are underway n the state level, thrugh Medicaid payments and health insurance regulatins as health insurers shw interest in reimbursing these services. In Maryland, the state has taken steps t refrm hspital payments rewarding health systems fr keeping patients healthy enugh that they dn t need hspital treatment. That adds financial incentives fr Jhns Hpkins and ther hspitals, encuraging them t use strategies such as cmmunity health wrkers xvii Effectiveness The federal Agency fr Healthcare Research and Quality s Preventin Quality Indicatrs (PQI) are cmpsite measures used with inpatient discharge data t identify quality f care fr ambulatry care sensitive cnditins that are avidable hspitalizatins in patients ages 18 years and lder. 6

8 PQI chrnic cmpsite rates were n a general dwnward trend fr Maryland and all five HEZs frm 2009 t All-cause, unplanned readmissin rates (per 1,000 ppulatin) decreased fr each HEZ frm 2012 t 2014 (data nt available prir t 2012) with the fllwing decreases in Maryland verall and by zne: Maryland: 14.8% Annaplis HEZ: 28.7% Drchester/Carline HEZ: 0.01% Prince Gerge s Cunty HEZ (PGCHEZ): 21.9% Greater Lexingtn Park HEZ (GLP HEZ): 39.6% West Baltimre HEZ: 22.8% Recruitment f healthcare prviders The Natinal Health Service Crps encurages states (like Maryland) and nn-prfit healthcare prviders t participate in its Lan Repayment Incentives prgram fr primary care prviders. In additin, sme states like Nrth Carlina have state-perated lan repayment prgrams fr healthcare prviders. In authrizing a lan repayment incentive t attract healthcare prviders t serve HEZ prgrams, the legislatin restricts eligibility t prviders that had graduated frm Maryland universities and clleges. This restrictin limited the HEZ s ability t attract healthcare prviders. In additin, lder practitiners wh may be attracted t relcating t rural areas n lnger have lans t repay. As a result, the HEZs petitined the DHMH fr the ability t cnvert the lan repayment funds t bnuses that culd be ffered t prviders and attract them t becme HEZ healthcare prviders. The tax incentive prgram fr healthcare prviders and facilities was a new and unique prgram fr Maryland. Its value has yet t be tested and evaluated because the regulatins and guidelines were nt ready until the secnd year f peratin. The cmplexity, newness, and delay in implementatin led the CBOs t step back frm this pprtunity. Subsequently, sme f the HEZs have requested the authrity t cnvert funds designated fr the tax incentive prgram t be used fr peratins and services. As f March 31, 2016, the HEZs have: Opened r expanded 20 health care delivery sites. Recruited and hired an additinal 75 FTEs, i.e. health care persnnel, including: 27 practitiner t prvide services in the HEZs 12 licensed independent practitiners, and 15 CHWs. The HEZ prviders and their clinics have cllectively prvided 255,194 visits t 139,211 patients. Sustainability Nw, in their final year f funding HEZs are earnestly develping sustainability plans t supprt their future activities. Their strategies are taking advantage f Maryland s All-Payer Hspital Payment Rate. In 2014, the Centers fr Medicare and Medicaid Services (CMS) and the State annunced a new hspital payment design that fcuses n verall per capita expenditures fr hspital services, as well as n imprvements in the quality f care and ppulatin health utcmes. Fr five years beginning in 2014, Maryland will limit the grwth f per capita hspital csts t 3.58% r 0.5% less than the actual natinal grwth rate fr 2015 thrugh 2018, whichever is less. The change is frecast t save Medicare at least $330 millin. Thus the HEZs with the legislated gals f reducing ED use, hspital utilizatin, ppulatin management thrugh CHWs, and enhanced primary care services t racial/ethnic residents and their disprprtinate rate f acute and chrnic illnesses have becme an integral part f a hspital s and Maryland s effrt t cut csts and save resurces. The revenue saved by the hspital, thrugh the services f the HEZs can thus be used t fund and sustain future HEZ prgrams activities and services. 2.2 Cmplementary Health Disparity Activities in Maryland The HEZs represent a cncerted effrt n the part f state plicymakers t address health disparities. At the same time, Maryland plicymakers are seeking t reinfrce and incrprate attentin t health disparities thrugh several parallel effrts, tw f which are: State Partnership Initiative Maryland s Office f Minrity Health and Health Disparities (MHHD) recently received a federal grant fr the purpse f Educating Minrities n the Benefits they receive after Enrllment. The Office s initiative aligns with the Federal gvernment s Cverage t Care initiative t assist cnsumers wh have enrlled in health insurance, thrugh the ACA, n hw best t use their newly acquired health insurance. The grant fcuses n newly enrlled racial/ethnic cnsumers living in specific zip cdes, thugh nt necessarily thse f the HEZs. Here again, Maryland is targeting zip cdes, gegraphic areas and establishing specific gals/targets: 7

9 T decrease the percentage f persns uninsured in the target zip cdes by 5 percent thrugh cmmunity health wrkers (CHWs) and referrals frm a hspital partner. T btain a 20 percent decrease in the target zip cdes, in the rate f ED visits r hspital admissins T hld cmmunity educatinal sessins t imprve health insurance literacy, and T help them vercme barriers t effective use f primary care services. T decrease, by 10 percent the number f Medicaid enrllees wh have nt had at least ne primary care visit in the last tw years. Cmmittee n Institutinal Cperatin Health Equity Initiative The University f Maryland are members f The Cmmittee n Institutinal Cperatin a cnsrtium f Big 10 universities plus the University f Chicag. The University f Maryland and DHMH alng with ther universities and their state health departments are cllabrating t blster health equity in their respective states. By understanding and addressing the scial determinants f health, the CIC Health Equity Initiative is pised t imprve the health utcmes f vulnerable children and infants acrss the eleven state regin f the CIC. 3. Nrth Carlina The 2015 reprts frm America s Health Rankings and Cunty Health Reprt and Radmap prvide cmprehensive and detailed facts and figures n Nrth Carlina s status, rankings and gaps. America s Health Rankings Overview f Nrth Carlina nted the state s verall ranking rse frm 36 th t 31 st. The rise in the rankings was due in large part t the percentage f children receiving their prescribed immunizatins, and the percentage f adlescent yung wmen wh received HPV immunizatins. It als nted the challenges Nrth Carlina plicymakers face. Table 3 Race Nrth Carlina Pverty by Race xviii Pct. Living in Pverty American Indian 34.8% Hispanic r Latin 33.9% African-American 28.4% Asian 13.1% White, nn-hispanic 12.2% State Average 18.0% Federal Pverty fr Family f 4 is $23,492 Furthermre, the reprt pinted t the large disparity in health status f Nrth Carlinians based n the level f educatin, a high infant mrtality rate, and the lw per capita spending n public health. Similar t AHR, the Cunty Health Rankings & Radmaps Building a Culture f Health Cunty by Cunty reprt, draws attentin t the gaps between the best t wrst ranked cunties in hw lng and hw well residents live. The annual reprt asserts that rankings make the case fr actin t imprve the pprtunities fr everyne s gd health, bth fr residents in ur unhealthiest cunties and fr thse wh d nt have a fair chance at achieving gd health in cunties that rank amng the healthiest. In 2015, America s Health Rankings fr Nrth Carlina include: 42 nd fr infant mrtality, 31 st in cardivascular deaths, 33 rd in cancer deaths, 26 th in the prevalence f besity, and 31 st verall, amng the 50 states. 8

10 Table 4 Cnditin Range Acrss NC s 100 Cunties xix Lwest Rate Highest Rate Infant Mrtality per 100,000 Live births 5 per 100, per 100,000 Adult Obesity 20% 39% Life Expectancy: Number f Deaths at r under age 75 per 100,000 peple 230 per 100, per 100,000 See Table 4 fr the disparity between Nrth Carlina s 100 cunties fr a select number f cnditins and statuses accrding t CHR&R. 3.1 Nrth Carlina s Effrts t Address Health Disparities Nrth Carlina s effrts t address health disparities lie with the NC Office f Minrity Health and Health Disparities (OMHHD) xx The Office s rle is t engage in prjects and activities in cmmunities acrss Nrth Carlina that prmte and advcate fr the eliminatin f health disparities f all racial and ethnic minrities and ther underserved ppulatins. The fcus areas include: 1) research and data; 2) culture and language; 3) leadership develpment; and 4) partnership develpment. Cmmunity Fcused Eliminating Health Disparities Initiative In 2005, the Nrth Carlina General Assembly established the Cmmunity Fcused Eliminating Health Disparities Initiative (CFEHDI) t clse the gap in the health status f racial/ethnic minrities, as cmpared t the health status f Whites thrugh the use f preventive measures t supprt healthy lifestyles. Administered by OMHHD, the fcus areas f CFEHDI are asthma, cancer, diabetes, heart disease, HIV/AIDS and ther sexually transmitted infectins, infant mrtality, besity, and strke. In additin, it seeks t successfully prepare cmmunity leaders and their rganizatins t becme effective and infrmed public health leaders, advcates, and partners. In the budget fr SFY the Nrth Carlina General Assembly apprpriated $2 millin t the Divisin f Public Health fr the OMHHD t award up t 12 new CFEHDI cntracts t the fllwing entities, with n entity receiving mre than $300,000. The cntracts were made in February See Table 5. In June 2016, the Nrth Carlina General Assembly enacted the SFY budget with language that directs the Department f Health and Human Services t stp all new grants frm the Cmmunity Fcused Eliminating Health Disparities Initiative. In additin, it reallcates the $2.7 millin frm the Office f Minrity Health and Health Disparities t the Injury and Preventin Sectin f the Divisin f Public Health fr cmmunity-based diabetes preventin. The reallcatin leaves the OMHHD with a minimum f resurces. OMHHD als is wrking t implement Health in All Plicies which is a cllabrative apprach f health care prfessinals and plicymakers t imprve the health f all Nrth Carlinians by incrprating health cnsideratins int decisin-making acrss all DHHS sectrs and plicy areas. Adpting this philsphy the Divisin f Public Health and OMHHD have sught t bring attentin t the medical and scial determinants f health disparities in the Department f Health and Humans Services decisin making prcesses. Culturally and Linguistically Apprpriate Services In 2013, the US/DHHS established the Culturally and Linguistically Apprpriate Services in Health and Health Care(the Natinal CLAS Standards) t advance health equity, imprve quality, and help eliminate health care disparities by prviding a blueprint fr individuals and health and health care rganizatins t implement culturally and linguistically apprpriate services. By tailring services t an individual's culture and language preference, health prfessinals can help bring abut psitive health utcmes fr diverse ppulatins. NC OMHHD ffers CLAS trainings and technical assistance t rganizatins and cmmunity members interested in learning mre abut cultural cmpetence and the Natinal CLAS Standards. The gal f the CLAS Prgram is t equip rganizatins with the infrmatin and resurces t address the changing demgraphics and health care needs f Nrth Carlinians. T date it has cnducted trainings in 37 cunties acrss the state. 9

11 Table 5 Cmmunity Fcused Eliminating Health Disparities Initiative (CFEHDI) SFY xxi CFEHDI AccessCare Appalachian Reginal Healthcare System, Inc. Buncmbe Cunty Health Dept. Cmmunity Health Interventins & Sickle Cell Agency Inc. Lincln Cmmunity Health Ctr. Lumbee Natins Tribal Prgram Hendersn Cunty Hspital Crp. Margaret Pardee Mem. Hspital Cunties Served Ppulatin xxii Alamance, Caswell, Chatham, and Orange Cunties 393,000 residents Avery and Watauga Cunties 71,000 residents Buncmbe Cunty 254,000 residents Cumberland and Hke Cunties 382,000 residents Durham 298,000 resident Cumberland, Hke, Rbesn, and Sctland Cunties 55,000 Members Lumbee Tribe Hendersn Cunty 112,000 residents Activities Diabetes and Heart Disease Cancer, Diabetes, Obesity, Heart Disease and Strke Cancer, Diabetes, HIV/AIDS/STDs/Obesity, Heart Disease, Strke, and Asthma Diabetes and HIV/AIDS/STDs Diabetes and HIV/AIDS/STDs Cancer, Diabetes, and Obesity Diabetes Onslw Cunty Health Dept. Sctland Cmmunity Health Clinic (FQHC) Suthern Piedmnt Cmmunity Care Plan, Inc. Wake Cunty Medical Sciety Cmmunity Health Fundatin Wayne Cunty Health Dept. Onslw Cunty 195,000 residents Sctland, and surrunding Cunties 36,000+ residents Cabarrus and Rwan Cunties 335,000 residents Wake and Jhnstn Cunties 1,195,000 residents Wayne Cunty 126,000 residents Diabetes Diabetes, Obesity, Heart Disease, and Strke Heart Disease Diabetes, Obesity, Heart Disease and Strke Diabetes, HIV/AIDS/STDs, Obesity, Heart Disease, and Strke 10

12 Cmmunity Health Ambassadrs Prgram Blue Crss Blue Shield f Nrth Carlina Fundatin The Cmmunity Health Ambassadrs Prgram (CHAP) engages faith cmmunities, health ministries, and health rganizatins t mbilize CHWs t implement infant mrtality reductin strategies in their perspective cmmunities and becme health influencers within their netwrks. DPH S CHAP aligns with ther DHHS effrt t develp a statewide supprt-system fr cmmunity health wrkers in Nrth Carlina. In 2015, the Blue Crss Blue Shield Fundatin awarded fur grants f $15,000 and ne grant fr $125,000 t assist CBOs t build capacity t address several issues invlving health disparities Nrth Carlina Fundatin fr Advanced Health Prgrams Under the leadership f the Nrth Carlina Fundatin fr Advanced Health Prgrams, the Nrth Carlina Rural Health Leadership Alliance (NCRHLA) is a crdinated netwrk f leaders and practitiners representing rural health rganizatins with a cmmitment t imprving rural health thrughut the state f Nrth Carlina. 3.2 Cmplementary Health Disparity Activities in Nrth Carlina Kate B. Reynlds Charitable Trust NCRHLA increases awareness f rural health issues by hsting wrkshps, distributing fact sheets, releasing psitin statements, and maintaining a webpage with rural health resurces. It prmtes cllabratin amng health agencies, health practitiners, and rural residents in the state by cnnecting and cnvening health interests and crdinating frums and wrk grups t discuss and fster implementatin f rural health slutins. In 2012, the Kate B Reynlds Charitable Trust (KBR) established a signature prgram t imprve the health and verall quality f life fr peple in rural Nrth Carlina Healthy Places Nrth Carlina. Residents in rural cmmunities are less likely t have access t health services, are mre likely t engage in risky health behavirs and have a higher mrtality rate n average than Nrth Carlinians living in nn-rural areas. KBR realized that imprving health invlves mre than imprving health care. Health challenges are ften driven by factrs beynd behavir and access t health care i.e. the scial determinants f racial/ethnic health disparities cited previusly in this issue brief. KBR specifically nted that rural cmmunities cnsistently have higher unemplyment rates when cmpared t urban cmmunities and mre rural residents live belw the federal pverty level.xxiii Similarly, Rural Frward NC prvides free cnsulting services t the peple, rganizatins, and calitins leading the effrt t build healthier rural cunties in central and eastern NC. It wrks in partnership with lcal, reginal, r statewide cmmunity leaders t supprt emerging effrts. In additin, it prvides reginal supprt fr KBR s Healthy Places Nrth Carlina. Healthy Places NC respnds t the needs f a cmmunity by listening t the peple, cperating with lcal changemakers, and wrking with them t find ways t imprve the health and verall quality f life. KBR believes that t have a lasting impact n majr health challenges, cmmunities must change the way they think abut imprving health, realize that health is everyne s business, and develp a diverse infrastructure t tackle health-related issues. Similar t Maryland plicymakers, KBR acknwledges that addressing gegraphic health disparities is nt a shrt term prject and plans t stay invlved in each f the fllwing cunties fr up t 10 years. Beaufrt Cunty Burke Cunty Edgecmbe Cunty Nash Cunty Halifax Cunty McDwell Cunty Rckingham Cunty 11

13 4. Nrth Carlina plicymakers shuld cnsider creating Health Enterprise Znes As t why Nrth Carlina state plicymakers shuld cnsider creating Health Enterprise Znes, let s examine Table 6 belw. Accrding t data frm America s Health Rankings Nrth Carlina ranks in the bttm half amng the 50 states in a number f key health indicatrs. Furthermre, NCDHHS data demnstrates the serius health disparity fr African-Americans frm the already distressing rankings fr Nrth Carlina, as a whle. Cnsider Stp thinking abut health as smething we nly get at the dctr s ffice: Instead, health is smething that starts in ur families, schls, wrkplaces, playgrunds and parks; The mre plicymakers see health in this manner, the mre pprtunities there will be t imprve health. xxiv Assess whether Nrth Carlina has fallen shrt in assisting cmmunities and individuals t develp a rad map f their wn n hw t achieve better health status. Table 6 America s Health Rankings nted that Nrth Carlina is challenged in this regard by its lw per capita funding f public health--$44 per capita versus a natinal average f $86. Infuse resurces based n need and ptential return n investment, while at the same time expecting cmmunities and individuals t take persnal respnsibility in utilizing these resurces. Take Steps Bth the America s Health Rankings and Cunty Health Rankings and Radmap reprts prvide ample justificatin and an excellent fundatin t build n. Build upn and adapt the cncept f Maryland s Health Enterprise Znes. The success f HEZs deserves serius attentin and cnsideratin n the part f Nrth Carlina plicymakers. Let s review the accmplishments t date f HEZs, which include: Engagement f cmmunity leaders; Use f ecnmic develpment and revitalizatin f public health and healthcare delivery; Fcus n a defined cmmunity and its residents s as t demnstrate a return n investment. Increase in the availability f healthcare prviders, including primary care physicians; America s Health Rankings 2015 Health Indicatr Nrth Carlina All Races African- American U.S N. 1 State Value Rank Value Value Value Obesity (% f Adult Ppulatin) 29.7% % 29.6% 21.3% CO Lw Birthweight (% f live births) 8.8% % 8.0% 5.8% AK Infant Mrtality per 1,000 live births MA Diabetes (% f ppulatin) 10.8% % 10.0% 7.1% UT Cardivascular Deaths per 100, MN Cancer Deaths per 100, UT Premature Deaths (years lst per 100,000 7, n/a 6,997 5,414 MN Public Health Funding (dllars per persn) $44 42 n/a $86 $227 AK Surce: America s Health Rankings 2015 and extraplatin f DHHS/DPH/State Center fr Health Statistics: Nrth Carlina Resident Ppulatin Health Data by Race and Ethnicity, Nvember

14 Reductin in health disparities; Emplyment f Cmmunity Health Wrkers t prvide ppulatin management; Imprvement in health utcmes; Reductin in health csts and hspital admissins and readmissins; Facilitate transprtatin and access t healthcare prviders, pharmacies, fd stres, and parks; Establish a pathway t HEZ sustainability by assisting hspitals t implement Maryland s All- Payer Hspital Rate. T create a radmap fr adapting Health Enterprise Znes t Nrth Carlina, state plicymakers will want t take the fllwing steps: 1. Ge-mapping the state; 2. Cnducting cmmunity listening sessins acrss the state; 3. Cnvene a statewide cnference and 4. Designing health enterprise znes that are cmplementary with ther multi-year effrts. 4.1 Ge-Mapping Nrth Carlina pssesses utstanding academic and state resurces t accmplish the necessary ge-mapping f sci-envirnmental and health determinants f health disparities at the zip cde level. Department f Health and Human Services, Divisin f Public Health The University f Nrth Carlina Gillings Schl f Public Health, that wrks with America s Health Rankings Sheps Center fr Health Research These resurces can be augmented with data frm: US Department f Agriculture s Ecnmic Research Service CMS interactive map t understand gegraphic disparities in chrnic disease. Cmmunity Cmmns, a nn-prfit rganizatin using U.S. Census infrmatin t prvide data and tls t imprve cmmunities and inspire change. Maryland and ther states have made excellent use f ge-mapping t identify the prevalence f sciecnmic and medical determinants f health disparities and thus identify zip cdes, cmmunities and cunties with racial/ethnic minrities that are experiencing an inrdinate higher rate f mrbidity and mrtality. Enhancing ge-mapping t the zip cde level, as Maryland did, allws state plicymakers t assist cmmunity leaders t develp a mre fcused radmap and a rute t mre effective and efficient use f resurces. As a result, cmmunity leaders are able t assume the respnsibility t develp a better return n investment with the resurces prvided. Equipped with this data, the cmmunity itself can apply principles f ecnmic develpment and revitalizatin f public health and healthcare delivery fr racial/ethnic minrities. 4.2 Cnduct Cmmunity Listening Sessins Energized and strengthened with public health data dwn t the zip cde level based n the ge-mapping, state plicymakers shuld cnduct listening sessins r frums acrss the state t learn frm the many and varied leaders at the cmmunity level. What d they believe are their biggest bstacles, needs, r gaps in addressing health disparities? What are they lacking? Is it funding, technical assistance, equipment, facilities, r healthcare persnnel? Recently, New Yrk State cnducted a series f Cmmunity Listening Sessins in areas defined as Minrity Areas (MA), e.g. areas with 40 percent r greater racial and ethnic ppulatins, and which bre a disprprtinate burden f pr health. The sessins utilized a cmmunity led, bttm-up apprach t identifying and discussing cmplex health and scial prblems. It allwed the cmmunity t establish its wn identity and set pririties, and discuss strategies that can achieve imprved health and lng-standing scial change. T ensure that individuals and families had an pprtunity t participate, the rganizers prvided child care services, alng with fd. State plicymakers will want t ensure the bradest participatin in these listening sessins. T d s they will nt nly want t cntact the usual list f health prfessin and advcacy rganizatins, but make sure t invite representatives frm the business cmmunity, public educatin, academia, including cmmunity clleges, faith-based rganizatins, civic rganizatins, agriculture, representatives frm the media, wh reprt n affected individuals and cmmunities, scial service prgrams, and certainly individuals and families frm the cmmunity. 4.3 Identify and Catalg Resurces T make the best use f current and future resurces, state gvernment will want t identify and catalg all federal, state, cunty, academic, and philanthrpic resurces that can affect health equality. This effrt may 13

15 well identify sme previusly unknwn surces f supprt and cncurrently ensure that all effrts are in supprt f each ther and cmplementary. 4.4 Cnvene a Statewide Cnference Based n the infrmatin gathered frm Cmmunity Listening Sessins and utilizing the data frm the gemapping, cnvene a ne-day cnference that brings tgether representatives at all levels frm the cmmunity-based rganizatins, the business cmmunity, faith-based rganizatins, educatin, academia, healthcare, philanthrpy, and municipal and state gvernment. Cncurrent sessins wuld be held t identify and discuss the scial and medical determinants f health disparities. General Sessins wuld explre the success f Maryland s HEZs and the ecnmic strategies and principles they are based n, alng with the activities, prgrams, and services prvided. Like Maryland, the gal f the cnference wuld be t develp an verall strategy that takes advantage f Nrth Carlina s strengths and is cmplementary f ther effrts. 4.5 Cmplementary Multi-Year Effrt Several f the HEZ accmplishments nted abve alng with the recmmendatins fr ge-mapping the state and the hsting f listening frums are cmplementary t the current Healthy Places NC prgram. The Trust is cmmitted t a lng-term investment f up t 10 years. Similarly, Maryland s HEZs are a fur-year effrt, with a specific and viable strategy fr sustainability that is being put int place. 5. Cnclusin The Health Enterprise Initiative is innvative in its design, and its apprach, has demnstrated its effectiveness in addressing health care pririty utcmes and disparities. A ntable key t their success and future sustainability is their ability t leverage new incentives enabled by systems changes at the federal level. By incrprating ecnmic develpment principles int public health, cmmunities in Nrth Carlina will have the pprtunity t develp a range f incentives t expand access t care, reduce health disparities, and imprve health utcmes in underserved areas by attracting primary care, dental and behaviral health clinicians and supprting cmmunity-level interventins t braden the scpe f care within a given cmmunity and thus address scial determinants f health. Primed and prepared with zip cde level data and the critical input frm cmmunity leaders, Nrth Carlina plicymakers have a unique pprtunity t plan, develp, and implement a health enterprise zne initiative that addresses the state s racial/ethnic health disparities that will cmplement and enhance Healthy Places NC. Visit What Wrks fr Health at cuntyhealthrankings.rg/what-wrks-fr-health fr infrmatin n these and ther strategies t imprve health in Nrth Carlina. i America s Health Rankings-Annual Reprt, United Health Fundatin, 2015 ii Smedley, BD; Stith, AY; Nelsn AR; Editrs; Unequal Treatment: Cnfrnting Racial and Ethnic Disparities in Health Care, Washingtn, DC Natinal Academy Press, 2003 iii Cunty Health Rankings & Radmaps; University f Wiscnsin, Ppulatin Health Institutes, 2016 iv Wlf, S; Braverman, P; Where Health Disparities Begin; The rle f scial and ecnmic determinants and why current plicies may make matters wrse, Health Affairs 30, N. 10, 2011, Pg v Ibid vi Ibid vii Ibid viii Cunty Health Rankings & Radmap, University f Wiscnsin, Ppulatin Health Institutes, 2016 ix Health Enterprise Znes, Maryland Department f Health and Mental Hygiene and Cmmunity Health Resurces Cmmissin, 2014 x America s Health Rankings-Annual Reprt, United Health Fundatin, 2011 xi Maryland Health Enterprise Znes, SB 234 (Chapter 3 f the Acts f 2012) xii Health Enterprise Znes, Maryland Department f Health and Mental Hygiene and Cmmunity Health Resurces Cmmissin, 2015 xiii Ibid xiv Health Enterprise Znes, Maryland Department f Health and Mental Hygiene and Cmmunity Health Resurces Cmmissin, 2015 xv Maura Dwyer, Michelle Spencer, Maryland DHMH, persnal cmmunicatin, April 12, 2016 xvi Ibid xvii Luthra, Shefali; Hspitals eye cmmunity health wrkers t cultivate patients success; Kaiser Health News, April 11, 2016 xviii What Maryland s all-payer mdel teaches us abut the future f payment refrm, The Advisry Bard, May 13, 2016 xix Cunty Health Rankings & Radmap, University f Wiscnsin, Ppulatin Health Institutes, 2016 xx Wright, Crnell, Purpseful partnering: engaging the minrity cmmunity in the prgrammatic prcess, Office f Minrity Health and Health Disparities, NC DHHS, January 21, 2016 xxi Office f Minrity Health and Health Disparities, Divisin f Public Health, NC Department f Health and Human Services, April 2016 xxii Ibid xxiii Healthy Places, June 2016, retrieval frm 14

16 A COMEBACK SHORT OF THE MARK: Incme Trends in Nrth Carlina Cpyright All rights reserved.